Discussion of public health and health care policy, from a public health perspective. The U.S. spends more on medical services than any other country, but we get less for it. Major reasons include lack of universal access, unequal treatment, and underinvestment in public health and social welfare. We will critically examine the economics, politics and sociology of health and illness in the U.S. and the world.

Wednesday, December 26, 2012

As Noah says to the Lord in the famous Bill Cosby routine. As I may have mentioned before, I'm a lifelong -- well, since age 13 -- subscriber to Scientific American, which is probably why I'm such a know-it-all, even though they've been assiduously dumbing it down for the past few years.

Anyhow . . .

Michael Dettinger and Lynn Ingram this month tell us that once every couple of hundred years, California has been visited by the real, diluvean deal. Starting on Christmas eve in 1861 it rained not for 40 days and 40 nights, but for 43, after which the Central Valley was "an inland sea 300 miles long and 20 miles wide." Sacramento was 10 feet under. It took 6 months for the water to drain.

The most incredible fact about all that is that I had never heard of it before. Cal was relatively sparsely populated at that time, nevertheless thousands of people died. If that were to happen today . . .

Guess what. It will. They've been able to trace the record of such events in the sediment going back to 1150 or so, and they have convincing evidence of 5 of them. It turns out that great rivers of water vapor form in the atmosphere and west coasts generally are vulnerable to these events. And of course you know the kicker . . .

Global climate change should make them more frequent, by increasing the amount of water vapor in the atmosphere. If you thought Katrina and Sandy were exciting, well now. Words fail. A simulation of a lesser event -- only 23 days of rain -- found that 1.5 million people might need to be evacuated, with total economic costs of $700 billion. Given that nobody's getting 1.5 million people to high ground very quickly, again, well now. You figure it out.

That's why I'm not making any predictions for the New Year. Shit will happen.

Monday, December 24, 2012

Really. I believe I posted many moons ago about Richard Dawkins's idea to make "Atheists for Jesus" T-shirts.

I was just talking to a friend yesterday about the ascendancy of I-got-mineism in our politics, and the delusions that come with it -- that everything you have you deserve, nobody and nothing outside of yourself contributed to your deserved fortune, and every penny you pay in taxes is stolen to give to lazy parasites. That's not so weird in itself, but the alliance of this philosophy with the predominant form of Christianity in the U.S. is pretty strange.

My uncle was a preacher -- the pastor of Trinity Church on the Green in Branford, Ct, which is a national historical landmark. My mother was a Sunday school teacher. I got several perfect attendance medals for Sunday school, and I was talking about getting confirmed when I got old enough to figure out for myself that religion is bunk, i.e. thirteen years old.

But, the Christianity they taught me was the exact opposite of Rich Warren and Pat Robertson and Franklin Graham. They claim to interpret the Bible literally, and live by it. So how do they interpret this?

Matthew 25:31

31 “When the Son of Man comes in his glory, and all the angels with him, he will sit on his glorious throne.32 All the nations will be gathered before him, and he will separate the people one from another as a shepherd separates the sheep from the goats.33 He will put the sheep on his right and the goats on his left.34 “Then the King will say to those on his right, ‘Come, you who are blessed by my Father; take your inheritance, the kingdom prepared for you since the creation of the world.35 For
I was hungry and you gave me something to eat, I was thirsty and you
gave me something to drink, I was a stranger and you invited me in,36 I needed clothes and you clothed me, I was sick and you looked after me, I was in prison and you came to visit me.’37 “Then the righteous will answer him, ‘Lord, when did we see you hungry and feed you, or thirsty and give you something to drink?38 When did we see you a stranger and invite you in, or needing clothes and clothe you?39 When did we see you sick or in prison and go to visit you?’40 “The
King will reply, ‘Truly I tell you, whatever you did for one of the
least of these brothers and sisters of mine, you did for me.’41 “Then he will say to those on his left, ‘Depart from me, you who are cursed, into the eternal fire prepared for the devil and his angels.42 For I was hungry and you gave me nothing to eat, I was thirsty and you gave me nothing to drink,43 I
was a stranger and you did not invite me in, I needed clothes and you
did not clothe me, I was sick and in prison and you did not look after
me.’44 “They
also will answer, ‘Lord, when did we see you hungry or thirsty or a
stranger or needing clothes or sick or in prison, and did not help you?’45 “He will reply, ‘Truly I tell you, whatever you did not do for one of the least of these, you did not do for me.’46 “Then they will go away to eternal punishment, but the righteous to eternal life.”

Or this?

Mark 12

13 Later they sent some of the Pharisees and Herodians to Jesus to catch him in his words.14 They
came to him and said, “Teacher, we know that you are a man of
integrity. You aren’t swayed by others, because you pay no attention to
who they are; but you teach the way of God in accordance with the truth.
Is it right to pay the imperial tax[b] to Caesar or not?15 Should we pay or shouldn’t we?”But Jesus knew their hypocrisy. “Why are you trying to trap me?” he asked. “Bring me a denarius and let me look at it.”16 They brought the coin, and he asked them, “Whose image is this? And whose inscription?”“Caesar’s,” they replied.17 Then Jesus said to them, “Give back to Caesar what is Caesar’s and to God what is God’s.”And they were amazed at him.

Or this:

Matthew 19

16 Just then a man came up to Jesus and asked, “Teacher, what good thing must I do to get eternal life?”17 “Why do you ask me about what is good?” Jesus replied. “There is only One who is good. If you want to enter life, keep the commandments.”18 “Which ones?” he inquired.Jesus replied, “‘You shall not murder, you shall not commit adultery, you shall not steal, you shall not give false testimony,19 honor your father and mother,’[c] and ‘love your neighbor as yourself.’[d]”20 “All these I have kept,” the young man said. “What do I still lack?”21 Jesus answered, “If you want to be perfect, go, sell your possessions and give to the poor, and you will have treasure in heaven. Then come, follow me.”22 When the young man heard this, he went away sad, because he had great wealth.23 Then Jesus said to his disciples, “Truly I tell you, it is hard for someone who is rich to enter the kingdom of heaven.24 Again
I tell you, it is easier for a camel to go through the eye of a needle
than for someone who is rich to enter the kingdom of God.”

Now, I know that the scammers have all sorts of arguments as to why these passages don't actually mean what they appear to mean. But why don't we ever hear from other Christians who do believe in the words attributed to Jesus in the Gospels? Why do they cower under the pews? Just askin'.

Thursday, December 20, 2012

Via Balloon Juice, I came across this essay by Mark Ames, who apparently is something of an expert on rampage murder. His main focus in the linked piece is on the NRA, and I recommend it for that reason. Basically, he argues that by being batshit crazy, the NRA actually insures intense loyalty and passion on the part of its members, because it reinforces their tribalism and paranoia.

That's worth thinking about, but the point I want to make for this post is that the Newtown tragedy was not typical, in that the perpetrator had no evident connection to his targets. I have mentioned previously the socially isolated men who shoot up their workplaces when they are in one way or another robbed of their only source of dignity through their employment. The kids who attack their own schools also typically, in one way or another, feel humiliated or socially excluded.

Now we find the question of access to mental health services entering prominently into the post-Newtown debate. I'm afraid that while I agree we have problems with mental health services, that's largely an irrelevant distraction. The typical workplace or school shooter would not have contemplated getting mental health services. Workplace shooters often erupt after being fired, or disciplined, or having a conflict with their supervisors. There is seldom any indication in advance that they ought to get mental health treatment, and even if somebody thinks there is, there's no way to make them do it. Similarly, the school shooters are generally entirely unpredictable.

Now, it just so happens that Jared Loughner and James Holmes were recognized in advance as having serious mental illness, in both cases as it happens by school authorities. And their respective institutions reacted by expelling them and washing their hands of the matter. Loughner already has an official diagnosis of schizophrenia and obviously, Holmes will get one too. The Newtown shooter was also manifestly somehow wrong in the head, although we'll never get to slap a specific label on him. It's this run of bad luck which has apparently made mental health a big player in the current debate.

However. None of these people sought treatment. Putting a free psychiatry kiosk on every street corner would not have helped. The only thing that would have helped is making it impossible for them to acquire large capacity ammunition clips.

Tuesday, December 18, 2012

Jeffrey Sachs is of course correct. The amendment has to do with an archaic debate about federalism. It protects the state militias, not some bozo who wants to walk around the shopping mall with a gat on his hip so he can shoot any black kid who looks threatening, or a bunch of louts who think they can resist "tyranny" by taking on the United States army. The state militias are now the National Guard. That's the well-regulated militia. Back in the day, the militia members owned their own muskets, and kept them at home, which is why the amendment reads as it does.

The Supreme Court, in decreeing that a) this has anything to do with a "right" that pertains to individuals and b) has any application at all in the United States post about 1800, is legislating from the bench. This "interpretation" has nothing to do with conservatism or "original intent" or even jurisprudence. It's just a fraud. There is no such thing as gun rights, or gun owners rights, or a right to bear arms, deriving from the Constitution of the United States.

Monday, December 17, 2012

It's not exactly a revelation that you get a huge political advantage from attaching a label with positive associations to your cause. Rights, liberty, life, freedom,choice -- who could be against any of those? Respecting the right to bear arms gives us more liberty, more freedom, more choice, and we can defend our lives and our property. If you want to restrict that right, you want to take away my freedom. Obviously.

What's wrong with this picture? I shouldn't even have to point it out, yet somehow our public discourse can't arrive at the obvious.

People walking around with guns on their hips may feel that they have liberty and freedom, but they diminish the freedom of others. Who would dare to offend a belligerent character with a gun in his hand? Are the people of Newtown, and every other school district in this country, freer because their neighbors own high powered rifles with 30 round magazines? Of course not. They are forced to take all sorts of measures that restrict freedom in order to protect themselves. They have to make their schools, libraries, town halls and court houses less accessible. They have to tax themselves more to pay for police and security systems. Even so, sometimes their children get murdered.

I could play this argument out at greater length but others have done so better. The point is, liberty is always a problem of balance. Whatever liberty is granted to one person may take away from the liberty of another. Your liberty to dump your waste in the river deprives me of the liberty to swim in it.

Here's another powerful example. Banning smoking in public places turns out to have a huge effect on the incidence of heart attacks and acute respiratory distress. Huge. A twenty-one percent decrease in hospital admissions for acute myocardial infarction. That means smokers aren't poisoning other people, and the rest of us don't have to pay as much to take care of people who have heart attacks.

Libertarianism is sophomoric nonsense. Rand Paul and Ron Paul and everybody associated with the Cato institute are mindless. We must root this delusional thinking from our political discourse.

Sunday, December 16, 2012

Connecticut is a relatively small state in geographic extent, but Newtown is pretty far from me in Connecticut terms. I have never been there, and I had to look it up on a map. As it turns out, though, my brother-in-law's niece attended Sandy Hook, and her baby sitter's daughter was killed. And seeing my governor and senator on TV talking about it makes it seem somewhat close to home anyway.

As for why the guy did it, the answer to that is easy: he was batshit crazy. Nobody is worried about asking Jared Loughner, for example, why he shot the congresswoman and all those other people, because we know he can't give a meaningful answer. As this story by AP's Helen O'Neil discusses, we can't say there has been an increase in these rampage killings recently. The first one I remember was Charles Whitman, who climbed a tower at the University of Texas in 1966 and shot 45 people, killing 13. I was 12 years old at the time. When I was in college, a woman in combat fatigues shot up a nearby shopping mall, and 16 year old Brenda Spencer shot up a school yard in San Diego in the "I don't like Mondays" assault. Usually they're men of course: the Luby's cafeteria massacre, the McDonald's in San Diego, that Vietnam vet who attacked children in a schoolyard, the epidemic of postal service massacres, and more recently Columbine, Virginia Tech . . .

(As I write this, my neighbor is emptying a 12 round magazine. He needs to do that every morning.)

So these keep happening. The distribution in time may not show any obvious pattern, but the distribution in space does. The U.S. seems to be where it happens most often. Sure, there have been massacres in New Zealand, Scotland, and Canada in my memory, but each of them is unique in its particular country. (I'm leaving politically and economically motivated crimes, such as the Mexican drug cartel massacres, for another day. I'm just talking about rampage killings by unconnected individuals.)

Is it something in the culture? I don't really see any evidence of that. Charles Whitman, on autopsy, was found to have a brain tumor. Many of the perpetrators, including Loughner and James Holmes, are manifestly psychotic. We don't understand psychosis well at all; it isn't clear how the zeitgeist influences psychotic fantasies. Obviously you have to know that the CIA exists to believe it has implanted a chip in your brain, or to have heard of Alpha Centauri to believe that extraterrestrials are beaming messages at you from that particular location, but otherwise the form of the delusion is probably sui generis, in other words you could believe you were possessed by a demon. Same idea. So whether violent movies or video games actually make psychotic people violent is far from proven.

There is a pattern of workplace rampages by socially isolated men whose work is their only claim to dignity and who react when something goes wrong there, but I don't know that that is unique to the U.S.

But we all know what is unique to the U.S. The only time I have fired a rifle was at boy scout camp. The weapon had a bolt that you pushed up and pulled back to open the chamber. Then you inserted a single cartridge, pushed the bolt forward and down, and took your one shot. Guess what? If you're hunting deer, that's just as good as a semi-automatic Bushmaster with a 30 round magazine. You only get one shot and if you miss, and try shooting again at the fleeing animal, you are an irresponsible idiot. There is absolutely no reason for people to own semi-automatic weapons or large capacity magazines. They have nothing whatsoever to do with hunting or sport of any kind. They are designed for exactly one purpose, and that is to kill humans. That is the only purpose they are good for.

The arms which the well-regulated militia had the right to keep and bear were muzzle loading muskets. You'd pour black powder down the barrel from your powder horn, then shove a wad of paper down the barrel with a rod, then drop in a ball. Then you could aim and fire, once.

If I want to shoot the chuck that's eating my garden, or bag a turkey for dinner, the most I need is a double barreled shotgun. Break it at the breech, put in two shells, and you're good to go. If I had one, and I lost my marbles, I could maybe shoot two people. Not 26. It's that simple.

Thursday, December 13, 2012

Worldwide, heart disease and circulatory disease are by far the leading cause of death. No surprise there, but you might be surprised by the importance of chronic respiratory diseases in carrying off the old folks. Unintentional injuries -- falls -- aren't way up there in the rankings but they're pretty important. A broken hip is very often the beginning of the end.

There have also been some big changes since 1990. HIV of course has jumped way up, while other communicable diseases have tended to go down in rank.

Anyway, you get to visualize it all sorts of different ways -- try it, it's very informative.

Jonathan Chait has justly won a wanker of the day award or two, but I'll give him props for this. (No endorsement of the Puffington Host implied or intended.)

I'll put a slightly different spin on it, but the basic idea is correct. The reason the weeping orange man won't specify the spending cuts he's demanding in return for the revenue increases he also won't specify is that he cannot. The United States has a far less generous social safety net than other wealthy countries, our infrastructure is crumbling, our regulatory agencies are underfunded (and they spend little money anyway) -- the one place where we can actually find substantial savings is in the bloated military, while the Republicans have been running around screaming that it's dangerously underfunded since Obama took office. They also campaigned against Obama for cutting Medicare, and now they're complaining that he doesn't want to cut it enough. Not that simple logic ever mattered in political discourse but . . .

The fact is that at some point, Congress is going to have to sit down and pass appropriations bills, and reauthorize the major entitlement programs. Fiscal cliff or not, debt ceiling or not, Orange Julius's House of Representatives is going to have to specify how much the federal government will spend on each and every one of its functions. They can cut funding for stuff they don't like, such as the EPA, but that will have a trivial impact on the budget deficit. They can cut spending on Medicare, but there are only two ways to do that:

Payment reform and cost-effectiveness guidelines. They claim that is equal to "death panels," so they won't do that.

Reducing benefits. That's not going to win them any love in 2014.

They could try cutting Medicaid benefits and tightening eligibility standards. That won't pass the Senate and if they did it, they would get the blame for horrendous consequences. At some level, the sane among them know that.

And they can cut the military budget, but they won't do that.

So they're stuck. The low IQ members may not understand that, but Boehner does. He knows it perfectly well.

Wednesday, December 12, 2012

I really like this piece because we gave voice to people who have been through really tough times and in most cases, overcome. But it required fundamentally changing how they thought of themselves and how they related to the world.

This is one of the consequences of a chronic disease diagnosis -- in this case HIV, but it happens to some extent with heart disease, chronic kidney disease, cancer. The doctor pronounces the word and the world changes. You are still the same person, but in a sense your identity is altered, where you are in the world is different.

Most of these folks, ultimately, made the most of it. But I don't know what the magic pixie dust is that can get people to successfully incorporate the new reality and move ahead courageously. Nor can they say what it was. At some point, it just happened.

Monday, December 10, 2012

While it is true that only a few people are convinced that the apocalypse will occur on a specific, known date, it is tragically also true that there are a lot of people -- I don't specifically remember the polling on this and maybe somebody can come up with a number, but it's close to half of Americans -- believe that it will happen sometime soon, they just can't say exactly when.

You may be old enough to remember that Ronald Reagan's Secretary of the Interior, James Watt, believed that, and said so publicly. He said that environmental conservation was pointless because the environment wasn't going to be around much longer anyway. Yes, that really happened. And maybe that's one reason among several that the looming catastrophe of climate change is largely ignored.

The failure of the Doha climate conference ought to be the top headline in every media outlet. It was buried in a small item inside the NYT this morning and is basically nowhere to be seen on the web sites of the major news networks. But the Reuters story (linked above) gets it right.

At the end of another
lavishly-funded U.N. conference that yielded no progress on
curbing greenhouse emissions, many of those most concerned about
climate change are close to despair. . . .

The conference held in Qatar - the country that produces the
largest per-capita volume of greenhouse gases in the world -
agreed to extend the emissions-limiting Kyoto Protocol, which
would have run out within weeks. But Canada, Russia and Japan
- where the protocol was signed 15 years ago - all abandoned the
agreement. The United States never ratified it in the first place, and
it excludes developing countries where emissions are growing most
quickly.

Delegates flew home from Doha without securing a single new
pledge to cut pollution from a major emitter. . . . A series of reports released during the Doha talks said the
world faced the prospect of 4 degrees Celsius (7.2F) of warming,
rather than the 2 degree (3.6F) limit that nations adopted in
2010 as a maximum to avoid dangerous changes. According to the World Bank, that would mean food and water
shortages, habitats wiped out, coastal communities wrecked by
rising seas, deserts spreading, and droughts both more frequent
and severe. Most impact would be borne by the world's poorest.

No, this is not the end of the world. It's not the end times. The universe will go on. But it will be hard times indeed, harder than we have ever known, and that includes World War II and the Dark Ages. Wake the fuck up.

Saturday, December 08, 2012

. . . in just a couple of weeks, my curiosity has again been awakened about why so many people believe in this particular category of balderdash, continually through the ages. This story about the followers of Harold Camping casts a bit of what little light there is to be found, but leaves me unsatisfied. (The on-line magazine Religion Dispatches, from which this is taken, is a good resource, BTW. They write about religion from the outside, without hostility but with appropriately critical thinking.)

As you may recall, Camping was the radio preacher who convinced thousands of people that the apocalypse would occur on May 21, 2011. They quit their jobs, spent their savings promoting the truth to the world, left their kids without college funds, abandoned their homes . . .

Spoiler alert: It didn't happen. The universe sailed on as serenely or tumultuously as ever. But why did they believe this? They weren't just betting on it. They were absolutely certain, as certain as the sun would rise on that day, the earth would be devastated by massive earthquakes, and then the rapture and the end of the universe would occur in October. Which also didn't happen, by the way.

It turns out that many of them are engineers or otherwise mathematically trained. They figured it out, by elaborate reconciliation of scriptural passages. The numerological and textual relationships they found in the Bible could not possibly have been coincidences, they were irrefutable evidence of the truth of the prophecy. Well, okay, but you really have to try very hard to get to that conclusion. Confirmation bias can't happen until you already believe. There's still a piece missing here.

But come to think of it, the same can be said of all religious belief. It's just that much of it doesn't smash to pieces against observable reality quite as hard. Anyway, I'm puzzled.

Two and a half years after the law’s passage, six in ten Americans either believe that the health care law establishes a government panel to make decisions about end‐of‐life care for Medicare beneficiaries (39 percent) or are not sure whether or not this is a provision of the ACA (22 percent). The numbers among seniors are very similar: 32 percent of seniors believe the law sets up such panels, 28 percent are not sure. Two in three seniors say the law cuts benefits for people in the traditional Medicare program. In fact, there are no actual cuts in benefits for beneficiaries in the traditional Medicare program, though those enrolled in Medicare Advantage plans may see fewer supplemental benefits once reimbursements to those plans are reduced.

A lie is half way around the world before the truth gets its boots on. The Republicans have succeeded in lying to people, and the corporate media have enabled their lies. This must end, or there is no hope for us.

Tuesday, December 04, 2012

The new policy at NIH is that all publications resulting from NIH funding have to be posted to a repository called PubMed Central for open access after one year. Here's one of mine, that went live today.

Many people -- both doctors and patients -- complain that there isn't enough time in a standard medical visit. In order to make their boat payments, doctors typically average 12 to 15 minutes for regular outpatient visits. In fact, there isn't much evidence that visits used to be a lot longer, but medicine, and life, have gotten more complicated, and that amount of time seems less adequate than it used to. Of course a higher percentage of patients are older and sicker than in the past, and of those who are sick, there's usually more to be done. In addition, we're managing diagnoses that didn't used to exist - "pre-diabetes," high LDL, and so on.

The people in our study all had HIV, and they were visiting HIV specialists, but for these patients, as for most people with HIV, the HIV doc is also their primary care doc. Most of them were doing reasonably well, so these visits, on average, weren't a whole lot longer than 15 minutes. But, they varied a lot. Using a coding method of my devising, we found that longer visits tended to appear to be more "patient-centered" -- less physician verbal dominance (i.e., doctors normally talk more than patients but it was more even in longer visits), more patient questions, more patient expressive utterances, that sort of thing.

As you will often find with me, there's a "but" -- when we looked directly at the really long visits, many of them seemed more patient centered because a lot of what went on wasn't really medicine. In one, the patient spent most of the time griping about his siblings who were squabbling with him over his mother's estate. In another, the doctor spent several minutes teaching the patient about the history of South Africa. In another, the doctor tried to recruit the patient to go to church with her.

So it's not that simple. We're there on business. Most of us expect efficiency and likely value quality over quantity when it comes to interacting with our doctors. In fact, my own mother happened to volunteer to me the other day that she really appreciates how her ophthalmologist concentrates on business and doesn't get into a lot of chit chat. She adores him, but it's because she trusts him to take care of her eye (she only has one), not because he's all up in her stuff. That makes sense to me.

In a nutshell, the researchers sliced up the donated brains of a bunch of football and hockey players, and some combat veterans (many of whom had played football) and found most of them had brain damage that looked kind of like Alzheimer's disease. They were able to correlate what they saw under the microscope with reported symptoms that they maintain define four stages of traumatic encephalopathy.

Now to unskew. This is actually what we call an existential or phenomenological study. It does not give us information about the prevalence of this sort of damage among football or hockey players. True, this sort of damage was not found in the (fairly small) number of controls they looked at, but these guys' brains were donated in the first place because the families were worried that something was wrong. What this study is telling us more about what can happen to people who suffer repeated blows to the head, but it does not mean 68/85 of football players (or hockey players or combat veterans) actually have this sort of damage.

We still don't know that number, and we don't know a whole lot about the details of what puts people at risk. Maybe some people are more susceptible for reasons of underlying physiology. Maybe particular patterns of injury -- with respect to frequency, age of occurrence, severity and specific physics of the blows, etc. -- are much more dangerous than others. Conceivably, growing awareness among coaches and policies to prevent repeated concussions in a short time have already reduced the risk. We don't know . . .

But. Clearly there is a risk. It seems based on casual observation at least to be quite substantial for professional football players but it also seems to be more than most parents would tolerate even for high school, and certainly for college players. This is quite unpleasant for me to face up to because I am a lifelong pro football fan. They're giving us cheap entertainment and yeah, some of them get fame and fortune but a lot of them only last a couple of years and end up with battered bodies, little in the way of marketable skills, and a few bucks to show for it. Then this disease -- first headaches and depression, then personality changes including angry outbursts, then loss of ability to plan and motivate, then dementia.

You can argue that grown men who take on this risk voluntarily can do what they want. Maybe. But if mothers won't let their sons play, the game will fade away. What other people think doesn't matter. That will be the end of it.

Friday, November 30, 2012

Just in case people are curious about what I do for a living, here are my recent and current activities.

1. I just got a paper accepted and revised the page proofs. It's a focus group study of people living with HIV about their experience communicating with their doctors about adherence to antiretroviral medications. It's an open access journal so as soon as it's on-line I'll give y'all a link.

2. I revised and resubmitted another paper, about a new system I developed for coding and analyzing clinical encounters. The system is also part of the basis for . . .

3. An award from the Patient Centered Outcomes Research Institute to study how features of clinical communication in chronic kidney disease and heart disease are related to patients' understanding and recall of the information they get and the treatment decisions that are made in a visit. Right now we're finishing up the interview guides and protocols and waiting for IRB* approval.

4. I finished drafting a paper on racial and ethnic differences in patient-provider communication in HIV care, based on our system for coding and analyzing interactions, and sent it to a co-author.

5. I'm in the middle of a study called Explanatory Models and Decision Heuristics in HIV Care. I did a whole bunch of semi-structured interviews with people living with HIV, to find out what they understand and believe about HIV and HIV treatment, and how that affects whether they take their pills and so on. Now my mission is to develop a structured survey that can be given in waiting rooms to find out what conversations people really need to have with their docs and/or nurses. (It turns out, BTW, that people who tried this with kidney disease found out that 1/3 of people living with chronic kidney disease do not know that the kidneys make urine. Really.)

6. I'm supposed to be analyzing data from another survey I was involved in, concerning people's perception of risk from near-highway pollution. Need to get cracking.

7. I'm working on a proposal about communication between providers and families, and how well families follow medication and infection control protocols, for kids who have hematopoetic stem cell transplants (AKA bone marrow transplants, although they don't literally transplant bone marrow.)

8. Two more papers I'm supposed to be writing . . . will get a round tuit.

I probably forgot a couple of things. In fact I know I did. Anyhow if anyone has questions about any of the above, or would like to learn more, let me know.

* Institutional Review Board. They're supposed to protect the rights and interests of human research subjects, but they can often be a source of petty bureaucratic annoyance.

Thursday, November 29, 2012

Check out Science works for us, a web site created by a consortium of research universities to explain why threatened cuts in federal funding for scientific research will be bad for the economy, and bad for you. (They even have a map you can click on to see what will happen to funding that comes to your state.)

Yeah yeah, federal spending on scientific research is soshulism. Here's the problem Sen. Paul: knowledge is a public good. That means that even according to the bogus Economics 101 theory you embrace, it won't be produced in sufficient quantity by private enterprise. Of course, you don't believe in scientific conclusions anyway, you prefer that we remain ignorant.

If congress doesn't act affirmatively before January 1, federal funding for scientific research will be reduced immediately by 8%. It's already the lowest it's been in a decade, in real dollars. Funding for research (and that includes the military, BTW) is only 2% of the federal budget, but it generates huge profits for society, part of which is returned to the treasury in taxes.

Making these cuts will be absolutely nuts. Write or call your representatives in congress and tell them to make sure it doesn't happen.

Tuesday, November 27, 2012

Okay, the most obvious reason why people sell bunkum is just that -- to obtain money. Pat Robinson has managed to get very wealthy by conning the rubes, but every preacher is out to make a living. True, you don't have to be a creationist to get people to put money in the plate but having your own special truth to which those smart people who laugh at you are hostile builds tribalism and loyalty and helps shake out your pockets.

The same motive applies to homeopaths and naturopaths and chiropractors. They couldn't get into medical school or didn't want to make the serious effort it requires, but this way they get to pretend they are doctors and get a fee.

Most con artists start believing their own bullshit -- it makes them more effective a the con and lets them live with a clear conscience. So they also get to believe they are actually helping sick people or saving souls. It makes the money even sweeter. So these cases are not hard to explain.

Climate change denial is rather similar -- it's mostly financed by the fossil fuel industry and associated tycoons. Just follow the money.

But that doesn't entirely explain why lots of people who aren't making money off of these schemes become passionate believers. These frauds sell in large part because the truths they deny are inconvenient, uncomfortable to downright distressing, or take some hard work to really understand. It feels better, at least for many people, to believe the bunkum, and once they start believing, confirmation bias, tribalism and just avoiding the conclusion that you've been duped all reinforce and maintain the belief against all evidence.

That doesn't explain, for example, Peter Duesberg, the virologist who to this day maintains that HIV does not cause disease. It's cost him career advancement and the respect of his colleagues and gained him nothing, as far as I can tell. But here's what seems to have happened.

When the HIV hypothesis was first proposed, like any hypothesis it took some work to confirm. At the early stages of any emerging scientific idea, it's appropriate to question it, push back, and really make the proponents of the hypothesis prove it. Indeed, most of the time they turn out to have been wrong. If the hypothesis holds up, and the critics say fine, you have overcome my objections, they shouldn't pay any price, in fact they should gain respect. But the dynamic doesn't always work that way, either within the relevant community or the individual critic's psyche. In the process of arguing with his colleagues, Duesberg evolved from a friendly critic to an adversary, and came to see conceding that HIV causes AIDS as a personal defeat. His self-esteem just wouldn't allow it. In other words it was a case of confirmation bias run amok.

The problem is what to do about it. Presenting people with ironclad evidence and irrefutable logic that says they've been just plain wrong all along doesn't work with most folks, most of the time. It just makes them resent you and dig in even deeper. Viz. Duesberg. So we come to an impasse.

My colleague Steve Sloman has an idea. Most people have what he calls the illusion of explanatory depth: they think they have a very sound basis for their belief but it turns out they really can't explain why they believe it or defend their belief effectively if you ask them. Don't tell them they're ignoramuses or dupes, ask them to explain it to you. They may suddenly find they can't.

Monday, November 26, 2012

I'll get back to the deep epistemological thoughts soon, but a couple of noteworthy studies have come out over the holidays, in the general vein of less is more.

First, I'll bet your doctor has you come in for an annual checkup, assuming you are fortunate enough to have health insurance. Don't bother. Based on a systematic review, some Danish folks whose names I won't repeat because I don't know how to make the "O" with a / through it conclude that "General health checks [i.e. checkups] did not reduce morbidity or mortality, neither
overall nor for cardiovascular or cancer causes, although they increased
the number of new diagnoses. Important harmful outcomes were often not
studied or reported." In other words, they don't make you any healthier or make you live any longer, they just get you more diagnostic labels. And, obviously, cost money. Maybe we wouldn't have such a shortage of primary care providers if they weren't busy wasting their time and ours.

See the doctor if you have a good reason to, such as symptoms you're worried about or you need a certificate or something. And of course, if you have a chronic disease that requires ongoing management. Otherwise, find something better to do.

And yet another analysis that should prompt second thoughts about screening mammography. Basically, based on data from the U.S. cancer registry called SEER, Bleyer and Welch conclude that somewhere close to 1/3 of the cancers found by routine screening would never have caused clinically significant disease; and the vast majority of the rest could have been successfully treated even if they were diagnosed later, after a palpable lump or other symptoms appeared. The basis of this conclusion is essentially that after screening became widespread, the rate at which early stage cancers were diagnosed went way up, but diagnosis of late stage cancers went down only a tiny bit. Simple arithmetic tells you that most of those cancers diagnosed by screening would not have ended up being diagnosed at a late stage. Also, this means that something like 70,000 women a year are "overdiagnosed," i.e. they are told they have breast cancer and treated for it, even though nothing bad would ever have happened to them if the "cancer" had not been found.

Again, I'm not a real doctor and I'm not giving medical advice. Certainly if your mother or sister had breast cancer, if you've had estrogen therapy, if you have never had children, you are at higher risk and have a stronger argument for getting a screening mammogram. But make your own decision -- don't let anybody pressure you to do it.

That said, this finding is not anti-medicine. Au contraire. The death rate from breast cancer has fallen a lot in the past two decades. But that is because of better treatment. Advances have been incremental so they haven't been much noticed, but they have been substantial. The contribution from screening to the lower death rate, if any, must be quite small. And by the way, better treatment is probably why screening doesn't turn out to be so valuable after all -- catching it very early isn't as important any more.

Saturday, November 24, 2012

Now that the election is over, we can finally start to talk about stuff that's real. I perceive a modest burst of assertiveness by scientists and the defenders of science. All of a sudden we're allowed to talk about climate change, Marco Rubio gets an actual hard time from the corporate media over the age of the earth, even Ross Douthat excoriates the Republican party for cozying up to creationism.

So I'm inspired once again to ponder why so many people are alienated from reason and reality. Now, this gets tricky. Obviously there are legitimate disagreements in this world, and the route we got from finding truth in ancient fables to figuring out that the universe is more than 13 billion years old, the earth about 4.5 billion years old, and the life we see around us and partake of results from the process of evolution by mutation and selection. If you haven't studied these matters in depth, it seems as though you're simply being asked to choose between justification from the authority of your preacher, or the authority of some snotty kid who got into Harvard whereas you never had the chance.

There isn't any magic ruler that tells us what's true. We can learn enough about a small part of science to convince ourselves, but to a considerable extent we do have to trust authority. The real heuristic we need is to choose between authorities. I can't prove to you the credibility of the standard model of particle physics or the pathogenesis of atrial fibrillation, although I can make a pretty good case for evolution.

I think there are a few different varieties of denialism. People cling to homeopathy for different reasons than they cling to creationism, or global warming denialism, or holocaust denialism, or AIDS denialism. We call these by the same term but they aren't quite the same phenomenon. I'll try to sort it out in the next post.

Wednesday, November 21, 2012

As New Englanders grimly contemplate a month or more of Gronklessness*,
an even more horrific prospect appears on the horizon: that president
Obama might remove John Kerry from the Senate to the Cabinet, whereupon
Scott Brown will rise from the grave, compelled yet again to devour
human brains.

Massachusetts law requires a special election to fill a Senate
vacancy. That's how Scott Brown became a senator in the first place.
Massachusetts Democrats don't have any compelling candidates to fill a
new vacancy. Just witness the ragtag band of Whotheheckareyous? who ran
against Elizabeth Warren in the primary.

But wait, it gets worse. Possibly corruptand definitely irresponsible
lieutenant governor Tim Murray is making noises about running. In a
well-financed campaign, he would be a gigantic human target.
Did I say well-financed? A zombie Scott Brown candidacy will be the
opportunity for the wounded and enraged financiers of the Romney debacle
to recover a shred of their dignity, and there will be no competition
for their money. Massachusetts will be carpeted a foot deep in cash.
Blimps advertising Scott Brown will hover over every city square and
village green. They won't just buy every commercial slot on radio and
TV. They'll buy the TV stations and run 24 hour Scott Brown
infomercials. They'll buy the Boston Globe, Worcester Telegraph and
Gazette, and Berkshire Eagle, and rename them respectively the Boston,
Worcester and Berkshire ScottBrownforSenate.

Brown has already proved he can win a bye-election, he already has an
organization and enthusiastic, experienced volunteers. The Democrats
had the candidate they wanted on November 6 and pretty even finances,
and Brown still outpolled Obama by something like ten points and made it
close until near the end. He'll get a sympathy vote this time around as
well.
Mr. President, please, in the name of all that is good and decent, don't do it! Sen. Kerry, think of the children!

*For those who don't follow the game where steroid abusers in plastic
armor beat the crap out of each other, that's New England Patriots
superhuman tight end Rob Gronkowski, out of action with a broken arm.

Tuesday, November 20, 2012

As a commenter who wandered over from Informed Comment to berate me on the previous post illustrates, and as David Atkins here laments, there are reasons - not exactly good ones, but reasons - why bloggers are wary of writing about the Israel-Palestine thing.

Nevertheless, I'll take a chance. First of all, just so you know, I was at one time professionally involved in Middle East related activism, as staffperson for an organization called the Lebanon Emergency Committee. This was a coalition formed in the Boston area following the invasion of Lebanon by Israel in 1982, in pursuit of the PLO. Yes, we wanted Israel out of Lebanon, among other objectives for both the Lebanese and the Palestinian people. Unfortunately neither has fared all that well since.

The fact is, the Israeli occupation of the West Bank, and the Israeli settlements there, are in violation of international law and several United Nations resolutions. There is a vast imbalance in power between Israel and Palestine, and the Palestinian people are simply being crushed, politically and economically, by a movement of settlers, mostly from Europe, who claim that God gave them the land on which the Palestinians have lived from time immemorial, and who are slowly, relentlessly, exercising this utterly absurd claim.

That's the basic reality. Are there Palestinians who deny Israel's right to exist? Certainly. But the international consensus since at least the 1960s, to which the Fatah leadership is committed, is that there should be two states.

I personally do not believe that in the modern world, we should be promoting nation states based on religio-ethnic identity at all. However, Israel is a fact, and there's no way to go back. Justice cannot be established in the past, but only in the future. And future justice demands that Israel uproot the settlements, leave the West Bank, and let the Palestinians work out their own future. Israel possesses an absolutely overwhelming advantage of military force and economic power. The country is in no existential danger. Any claim to the contrary is nonsense.

Those are among the starting points for any sensible discussion. And by the way, my comment that so provoked our guest was to condemn Hamas for launching rockets at Israel. This post, if noticed, will attract even greater outrage, I expect, from the opposite direction. As Atkins says, you can't win.

Monday, November 19, 2012

You have nothing to lose but Marco Rubio's brains, such as they are. The theory is that if the Republicans just nominate a Latino for president, it won't matter what their policies are or whether the rest of their candidates go around bewailing the threatened surrender of Anglo-Saxon civilization to the brown hordes, they'll finally get Latinos to vote for them.

Alas, having spent 15 years working for a Latino community based
organization, I can tell you from long, intense personal observation
that people whose heritage is from the predominantly Spanish speaking
countries of the Americas are not typically ignorant idiots, unlike the
Senator from Florida:

The senator, who has recently createdbuzz
about a potential presidential run in 2016, said that he is not
qualified to answer how old the Earth is, calling the question a
"dispute among theologians."

"I'm not a scientist, man. I can tell you what recorded history says, I
can tell you what the Bible says, but I think that's a dispute amongst
theologians and I think it has nothing to do with the gross domestic
product or economic growth of the United States," he told GQ Magazine.
"I think the age of the universe has zero to do with how our economy is
going to grow. I'm not a scientist. I don't think I'm qualified to
answer a question like that."

Note that he is even stupider than might appear at first glance. He explicitly says that the dispute is among theologians, not between theologians and people who actually know something and have arguments to make based on evidence; and he thinks that the age of the earth and the age of the universe are the same question.

Here's a dispute for the theologians. Which is stupider, Marco Rubio or a blastocyst? Either way, they're both human infants, right?

Friday, November 16, 2012

I just found out that something I wrote back in 2005 went comparatively viral, but I had no idea at the time. It's still relevant, I think, although the assertion in the third paragraph about current control of government is arguably out of date.

Living on the edge, but still taking up way too much space

Nov. 5, 2005

In my checkered youth, I was at one time a community organizer in
Philadelphia. I worked in black and white neighborhoods -- and believe
me, the city was completely segregated. I was an exotic sight in North
Phillie, but I never felt unwelcome there. In the poor white
neighborhood of Fishtown, however, I felt like an extraterrestrial.

Almost
everyone in Fishtown claimed to be a conservative, and expressed
scathing contempt for liberals. So what were some of their conservative
ideas? This was the time of the Arab oil embargo and (gasp!) gasoline
at a dollar a gallon. Many of Fishtown's rabid conservatives advocated
nationalizing the oil companies. Other popular conservative ideas
included government sponsored health care, a higher minimum wage,
stopping the developers who were deliberately creating blight so they
could buy up large tracts for upscale development, massive investments
in public transportation (the Kensington Ave. trolley was a foretaste of
hell), cleaning up the air pollution -- all kinds of radical right wing
ideas. They were mostly Catholic and went to church, but I can't
remember anybody giving a shit about abortion or keeping people on life
support.

Now, actual real conservatives have an iron grip over
all three branches of the federal government. In public opinion polls,
many more people label themselves conservative than label themselves
liberal. But a majority of people also tell pollsters that they are
willing to pay more taxes to protect the environment, improve the
schools, and do other good things; that they want universal health care;
that they want curbs on development to protect communities and the
environment; that they favor keeping Roe v. Wade (that one's not even
close -- 65% to 29%). 82% of Americans opposed intervention in the
Terri Schiavo case by the Congress and King George. In other words that
particular maneuver was less popular than legalized wife beating. And
oh yeah -- the majority favor sensible regulation of gun ownership.

Now,
back when I was knocking on doors in Fishtown the gay rights movement
was just emerging and nobody was talking about gay marriage. I'm sure
the Fishtowners would have opposed it had it come up. So score one for a
position more associated with conservatism. But looking at the
scoreboard, it's pretty clear that the supposedly democratically elected
government is generally sharply opposed to the majority of voters on
important issues of public policy.

What's going on? I confess I
have left out the most important issue that the good people of Fishtown
were worried about. In their own words, it was the niggers. They were
all on welfare, and they were taking all the jobs. (That's right, I
often got that in consecutive sentences. And by the way, I would
estimate that 1/4 of the households in Fishtown consisted of single
mothers on welfare, or disability pensioners.) They were going to push
us into the river. They don't keep up their own communities -- why some
of them moved in over in Kensington a couple of years ago and inside of
a year, half the houses on the block were abandoned. (Oh yeah, that's their
fault.) The nearest high school was dropping plaster on the kids
heads, and there was a proposal to build a new high school in Fishtown,
but the people were against it, unanimously. Why? Because black kids
might have walked through the neighborhood on their way to school.

Frank Rizzo, the racist neo-Nazi mayor, was very popular in Fishtown. Now you know why.

Politics
is complex. The right has cobbled together a coalition of minorities
-- people who are willing to trade off issues that aren't terribly
important to them for ones they really care about. Wall Street
financial barons and corporate executives want low taxes on high
incomes, minimal environmental and safety regulation, low wages and
minimal protections for workers, and they have plenty of money to put
into political campaigns. Most of them think the religious right
consists of ignorant lunatics, but they're happy to scoop up the wacko
vote for candidates who will favor the rich. The mass media, of course,
are part of the corporate establishment and naturally favor its
interests. Religious zealots may be in a minority, but they volunteer
for political campaigns, give what little they have, and vote as a bloc.
So that's an important part of the story.

But it is racism that
makes it all possible. It is largely because of racism that we have
such an underdeveloped social infrastructure compared with western
Europe and Canada. Racism has divided the working class, and made the
white majority mistrust social programs which they have been persuaded
somehow favor the other at their expense. It is racism, and nothing
else, that led to the ascendancy of the Republican Party in the states
of the confederacy, once the Democrats embraced the Civil Rights
Movement and resolved the contradiction between their role as the party
of the Old South and the party of the urban north. It is racism,
ultimately, that underlies the tendency of white Americans who hold
liberal views on issues to label themselves as conservatives. Racism is
still the central problem in this country. It still is. Yes it is.

Thursday, November 15, 2012

So I'm driving home last night and comes now Gary Loveman, operator of gambling casinos (audio link) who appears as a representative of the CEOs who met with the prez yesterday. He explains that we have to get the federal deficit under control, but if marginal tax rates are raised on the wealthy, it will destroy jobs. The mechanism is that rich people won't have as much money to gamble with, so he'll have to reduce some shifts.

Of course the interviewer doesn't challenge this. I mean, if you're the CEO of Caesar's, you're a serious person, right? I'm just a babbler on the radio, who am I to question anything you say?

At least we finally know how it is that the rich are the "job creators." They do it by gambling in Las Vegas. The Republicans had not gotten around to explaining that before.

Tuesday, November 13, 2012

I've written about this before, so first let me emphasize, no personal condolences or sympathy required, this happened many years ago and I'm fine now. Not to worry.

Without going into great detail, back when George Bush the First was bombing Iraq, I entered a Major Teaching Hospital of Harvard University through the emergency department. I had pain localized between my navel and right hip, with rebound tenderness and a fever. They told me I had acute appendicitis and they were going to take my appendix out. Eight hours after entering the operating room, I awoke severely dehydrated, in agony despite enough morphine to float William S. Burroughs for a week, and lacking my ascending colon. After opening me up they had seen, not appendicitis but rather a lesion that they decided was cancer but was actually diverticulitis. Eleven days and many travails and grievous errors and misjudgments later, I finally left the hospital.

I had insurance. However, they weren't happy with the amount the insurance company paid them. A couple of weeks later I received bills totaling more than $25,000 -- it would easily be twice as much in nominal dollars today. I told them to go pound sand and eventually they did but . . .

Hospitals get paid for doing stuff. The more stuff they do, the more money they make. Suppose you hired a roofer, who set up scaffolding incorrectly which caused a staging plank to crash through your living room window and smash thousands of dollars worth of antique glass. Would the roofer then bill you to repair the window and replace the artifacts? I think not. However, that's what hospitals do when the doctors make mistakes.

The linked article in Health Affairs reveals a major problem in efforts to control health care spending. If hospitals undertake quality improvement programs to reduce the rate of surgical errors and complications, they lose money. Not only do they have no incentive to do it, some small community hospitals might actually go broke if they didn't screw up so much.

In civilized countries such as the totalitarian dungeon to our north, hospitals are given a global budget to care for the needs of a community. It's in their interest to be competent, and efficient. So here's what we need:

We need universal, comprehensive, single payer national health care. Shout it from the rooftops.

Monday, November 12, 2012

The Affordable Care Act, it now appears, will continue its painfully slow march toward full implementation in 2014. This has always been the essential problem: most of the good stuff that's going to happen to people won't happen until then, and that's why the opponents of the ACA have been able to rant about socialism and government takeover of health care and death panels. Once people see for themselves that nothing bad happens, game over.

However, as Timothy Jost discusses, it's going to take at least a few tweaks and also a few bucks for the ACA to really work out well. The right wing governors will have to accept the Medicaid expansion after all. Specific insurance regulations need to be promulgated (Stat!). The federal exchange needs to be set up because it appears several of the states are not going to establish exchanges out of pique. (Ideologically inconsistent, I know, to prefer federal control, but they aren't making sense about any of this to begin with.) The House Republicans will no doubt try to use extortion over the debt limit, the fiscal cliff, and federal appropriations in general to mess up the thing, whereas it actually needs some technical corrections and constructive changes.

Whether the Republicans can get away with, or think they can get away with, continuing their strategy of trying to wreck the society and the economy in the hope that the opposition will get the blame for their own vandalism, I don't know for sure. But it's looking right now like they think they can get away with it. A well-informed, honest journalistic estate dedicated to the public interest would probably stop them, but we don't have that. Look forward to the continuing hail of BS, and wish us all luck.

Friday, November 09, 2012

And probably yours too. Yesterday, I had to take the day off from work to drive my mother to an appointment with a specialist physician. (Everything turned out okay.) They told her that her appointment with the doctor was at 3:00, but she should arrive at 2:30 to do all the paperwork. (So why can't they just say, "Your appointment is at 2:30"?)

So we got there at 2:30, she filled out the questionnaires, and at 3:00, they called her in to the examining suite. I then waited for 2 1/2 hours, until she finally emerged at 5:30. What the heck was going on? Answer: They did some tests, then she waited for the doctor for an hour and 40 minutes.

Now, this is a specialist. He comes to this clinic once a week, and sees only scheduled patients. He deals with no emergencies. When they book the day, they know every patient who is coming, why that person is coming, and what they are likely to have to do with that person. There is no good reason why they cannot see a person at 3:00 who is scheduled to be seen at 3:00.

The reason this happens is because of arrogance and a total lack of respect and consideration for patients. No other service industry could possibly get away with this.

Wednesday, November 07, 2012

The corporate media are, no surprise, only grudgingly conceding a Democratic victory, and pretty much universally describing the outcome of yesterday's election as essentially maintaining the status quo. It isn't.

1. The right has lost the culture wars: Gay marriage, contraception and abortion are losing issues for them now. They've lost that wedge almost everywhere. This is good news in itself, of course, but it's also an enormous clearing of the terrain for the liberal coalition.

2. Sheldon Adelson and the Koch brothers' billions couldn't buy the election because the fundamental premises behind their propaganda barrage were rejected by the voters. Yes Virginia, there is a role for government in creating a strong economy, boosting employment, and providing a safety net for the unfortunate. Rich people should pay more to help make those things happen. The basic social infrastructure of the New Deal and the Great Society is built into the bedrock of the political culture; it is unassailable, at least in 2012.

3. The right has lost the race war: It will never be possible to win an election by marshaling white racism and resentment. The changing demographics of the country rule that out forever.

4. The right has lost the generational battle: Their electoral base is dying and the 16-year-olds who will vote in 2014 will be overwhelmingly against them.

They only held onto the House because the 2010 wave election gave them control of legislative redistricting. That advantage will gradually fade between now and 2020 as congressional districts naturally change. The Senate is considerably more liberal. Finally, the corporate media may have finally found the right-wing lies just a little too much to include in the phony balancing act, and Fox News is no longer taken seriously. Oh yeah, the religious right's influence is also clearly withering.

This is really pretty good news. The republic may endure. Now if we can really start to do something about carbon emissions . . .

Monday, November 05, 2012

The difference is that Graham Spanier is doing it without a parachute. The president of Penn State University for 16 years, pulling down more than half a million a year in salary, traveling in the most rarefied of elite circles, and now he faces charges of perjury, obstruction of justice, and endangering the welfare of children. Whatever the outcome of the criminal case, Spanier's reputation in his own field -- family sociology and therapy -- is forever ruined. How could he possibly not have understood the likely implications of the reports he got -- on two occasions years apart -- about behavior by Jerry Sandusky that obviously, even to a layperson, raised very disturbing probabilities?

Well, the answer is, he did understand, and it seems to me quite evident from the smoking gun e-mail in which he approves a decision not to report the allegations against Sandusky to the authorities, but only to raise them with the executive director of Sandusky's charity, the Second Mile, and let him follow up.

The only downside for us is if the message isn't `heard' and acted upon,
and we then become vulnerable for not having reported it. The approach you outline is humane and a reasonable way
to proceed.

Penn State is a "mandated reporter," legally required to bring credible suspicions of child abuse to the attention of authorities.

The Catholic Church, PSU, the Boy Scouts, and now the BBC with the Jimmy Savile scandal -- all of these stories are eerily parallel. The Catholic Church's history of covering up child abuse was no surprise. It was pretty much common knowledge my entire life. People told jokes about it long before the Boston Globe's expose. I personally knew a guy who was viciously abused by monks at a Catholic boarding school, and another who grew up in a Catholic orphanage and, while he was not victimized himself, knew all about what was happening to other kids.

But having the same sort of tale emerge about one powerful institution after another is, I confess, a revelation to me. It seems more the norm than the exception for people in charge of organizations that are built on image and reputation to instinctively respond to this particular crime by ignoring the victims and protecting the perpetrators.

I'm still trying to parse out exactly what this tells us about the culture. Of course the people responsible are all men, and that includes the BBC which seems to have a very male dominated power structure. I can't prove that women in charge would have acted differently. So far we don't have any evidence about that, but I think most people will consider it a factor. However, it is certainly not my instinct, as a male heterosexual, to protect men who rape children. And I would like to think that my instinct as an organizational leader would be to put the organization's virtue ahead of its reputation . And even if I were entirely cynical, I hope I would be sensible enough to realize that the damage to reputation would be far worse if I got caught out after the cover up.

So I do find this puzzling. Raping children is, to most people, the most revolting of crimes. Yet it seems also to be the one crime that powerful men are least inclined to do anything about, if it might inconvenience the institutions that give them their power. I mean, if these people were stealing from the parishioners, scouts, Second Mile participants or kiddie show audience members, I'm pretty sure there would not have been a cover up. What gives?

Friday, November 02, 2012

We can always whip up an evil scum post by taking a look over at the pharmaceutical industry. Two pieces in the new BMJ (I think you'll just get the first 150 words or something but the Blog Oversight Organization requires that I provide links) skim the scum for us.

First, Medtronic corporation, a name you will find familiar should you be a totebagger. The Senate finance committee has found that they paid -- get this, it's not a typo or an extra zero -- hundreds of millions of dollars to doctors to pretend to be the authors of articles they drafted, edited and approved praising its product InFuse. Senator Max Baucus says, "Medical journal articles should convey an accurate picture of the risks and benefits of drugs and medical devices, but patients are at serious risk when companies distort the facts the way Medtronic has." Indeed. The editors of Spine Journal weigh in: "If surgeons had known that the lead authors of the 13 original studies on InFuse had received payments ranging from $1.7 million to $64 million [sic!] from Medtronic and that its marketing employees were co-authors and co-editors, would they have been as eager to use InFuse on their patients?"

That's all well and good but BMJ fails to name the names of those "physicians." They are all cruising along with high powered appointments and continuing to publish.

Along a somewhat different pathway of scummery, BMJ editor Fiona Godlee writes an open letter to Roche board member John Bell, "regius professor of medicine at Oxford University." Since it's open, presumably she doesn't mind if I quote it at length.

Dear John

I am writing to you in your capacity as a member of the board of Roche. As you may be aware, the BMJ
has been working with the Cochrane Collaboration in its efforts to get
Roche to release the raw data on the effects of oseltamivir (Tamiflu) so
that Cochrane can properly fulfil the UK government’s commission for a
systematic review of neuraminidase inhibitors based on clinical study
reports.

To remind you of the background to this, in 2009 the BMJ published the updated Cochrane review of neuraminidase inhibitors in healthy adults.1
This took the view that, since eight of the 10 randomised controlled
trials on which effectiveness claims were based were never published and
because the only two that had been published were funded by Roche and
authored by Roche employees and external experts paid by Roche, the
evidence could not be relied on. The BMJ also published an
article summarising the Cochrane team’s efforts to obtain the data from
these randomised controlled trials and a feature investigation exploring
the underlying issues.23

After
these articles were published, we and the Cochrane Collaboration
received public assurances from Roche that the data from these 10 trials
would be made available to physicians and scientists.4
Although some further data have been released to the Cochrane
reviewers, the data that were promised (“full study reports”) have not
been made available. . . .

The Cochrane reviewers now know that there are at least 123
trials of oseltamivir and that most (60%) of the patient data from
Roche’s phase III completed treatment trials remain unpublished. We have
concerns on a number of fronts: the likely overstating of effectiveness
and the apparent under-reporting of potentially serious adverse
effects. Meanwhile, oseltamivir has just been added to the World Health
Organization’s List of Essential Medicines, alongside aspirin and β
blockers.

On behalf of the Cochrane collaborators and
public health decision makers around the world, I ask Roche to honour
its publicly stated promise to make available the full clinical study
reports. In order for the Cochrane collaborators to properly analyse
these data they will need individual patient data in electronic format.

Oseltamivir
has been a great commercial success for Roche. Billions of pounds of
public money have been spent on it, and yet the evidence on its
effectiveness and safety remains hidden from appropriate and necessary
independent scrutiny. I am appealing to you, as an internationally
respected scientist and clinician and a leader of clinical research in
the United Kingdom, to bring your influence to bear on your colleagues
on Roche’s board. As company directors, responsibility for Roche’s
behaviour rests with you, as individuals and collectively. In refusing
to release these data of enormous public interest, you put Roche outside
the circle of responsible pharmaceutical companies. Releasing the data
would do a great deal to restore confidence in the company and its board
of directors.

As you may recall, during the Great Flu Pandemic Hoax of three years back, the World Health Organization and many national governments paid megabucks to stockpile the stuff. That's your money. It's you who got ripped off.

Personal note: I'm still without electrical power but I think of it as a kind of penance. My neighborhood wasn't burned to the ground or washed into the ocean, my children didn't disappear into the raging waters, I didn't lose my business and I'm not freezing or starving. I'm blogging from work where I can also take a shower and get a good meal. Not so for millions of people.

Thursday, November 01, 2012

I’m
getting in touch to introduce you to our client Vault Couture. Vault
Couture is an innovative, luxury membership service designed for those
seeking the ultimate
wardrobe-management solutions. Founded last year, the idea of Vault
Couture came about when the Founder, businesswoman Mounissa Chodieva,
realised that there was to date no service which would provide her with
the very best assistance in managing her wardrobe
needs.

These
needs, shared by the majority of her time poor, professional friends,
included lack of storage in her London home – which simply didn’t offer
enough cupboard
space for her ever increasing wardrobe! She found, like many women,
finding an outfit to wear in the morning from her vast wardrobe was a
stressful affair, coupled with the fact she was fed up of having to take
lots of luggage whenever she travelled on business
in order to ensure she had the right outfit for all the occasions on
the trip. Mounissa noticed there was a gap in the market for a service
which could manage her wardrobe as well as assisting her with styling
what she already owned and getting rid of garments
which she found she never wore any more.

And
so, the idea for Vault Couture was born, a membership service which
offers an easy way to find an outfit from your wardrobe in the morning
as well as style
looks for the day/week/month ahead - eliminating that ‘panic dressing’
we all suffer from due to lack of time. In addition she created a
state-of-the-art storage facility in London for her clients without
enough space
in
their home wardrobes or who didn’t have a home in London and only come
to the city on business. Vault Couture now offers a fast and reliable
collection and delivery service of garments
to any worldwide destination – all at the click of a button.

I
would love to tell you more about the company and hear if this is could
be of interest for your readers, please find attached more details on
the services
offered by Vault Couture along with a few images.

Wednesday, October 31, 2012

My grandmother's sister lived in Ventnor, New Jersey, the town next to Atlantic City. As a matter of fact they lived on Ventnor Avenue, with which you are familiar if you have played Monopoly. When I was a kid, we used to visit in the summer. Aunt Mary and Uncle Oby didn't have kids so they shamelessly spoiled us. Uncle Oby was a local macher so he had free passes to all the rides on the Steeplechase Pier. They took us -- me, my siblings and cousins -- to all the shows on the Steel Pier: Herman's Hermits, Dave Clark Five, Wilson Pickett. We'd go to watch the diving horse and walk along the boardwalk scarfing up the salt water taffy, cotton candy, Planters Peanuts (they had a guy in a giant Mr. Peanut costume) and Taylor fried pork roll (basically a Spam competitor but a greasy treat for a kid). It was the greatest!

Atlantic City hasn't been all about the wholesome family entertainment since they sold out to Donald Trump and the Mafia and brought in casino gambling in the '70s. But the Boardwalk and the Steel Pier were still there. Until Monday, that is. The Atlantic City boardwalk has been destroyed, and judging from the pictures, the Steel Pier is history. At least half of it is gone and I'm guessing they won't rebuild it.

I don't know whether the ocean made it as far as Ventnor Avenue, which is the second avenue paralleling the ocean behind Atlantic Avenue. I don't know whether Aunt Mary and Uncle Oby's house is still standing. Of course they died a long time ago and I haven't been to Atlantic City since I was maybe thirteen. I did visit Avalon, further south on the Jersey Shore, when I was in college. But anyway that whole area is deep in my family lore and my fondest childhood memories.* Now it's gone, just gone. Gone. The governor has said the Jersey shore will never be the same, and I'm sure he is right.

Was this a natural disaster? Partly. But it was also one of the greatest monuments to human folly of my lifetime. Yes of course war is a great folly and we've had plenty of wars that have been even more destructive and killed far more people. But these events will just keep happening, all around the globe. Good luck to us all.

* Don't know what to make of it, but of course Bruce Springsteen's famous ode to Asbury Park is subtitled "Sandy." According to the narrative of the song Sandy was his goodbye girl as he prepared to set out to make his fortune. "For me this boardwalk life's through, you ought to quit this scene too." The Asbury Park boardwalk is gone too, but I expect they'll rebuild that one. Haven't heard what happened to the Stone Pony.

Update: Friend Steph says the section of the AC Boardwalk with the main attractions is in decent shape. That's good to know. Of course the social and economic decline of the old Atlantic City was only accelerated by casino gambling, not arrested.

Tuesday, October 30, 2012

My power went out last night so I'm blogging on batteries. The power company gives no estimate of when I'll get the juice back, no blame there I'm sure there's just starting to get an idea of what they are facing. The political future just got even more critical, it seems to me.

There is some tragedy here, and a lot of pain and a whole lot more inconvenience and economic cost. But it's also an opportunity, potentially a wake up call. We'll have to do a whole lot differently from now on, from improving Manhattan's defenses against the rising ocean to stringing power lines that can withstand a twig falling on them to moving development away from the coast, and a whole lot more of that mitigation and adaptation. That means a huge amount of public investment.

Most important, of course, we need to stop spewing so much CO2 into the atmosphere.

Electing Mitt Romney, who wants to drastically cut the budget for disaster aid and reduce FEMA to block grants because nobody likes FEMA anyway, and who says he doesn't believe that humans are causing climate change, and who says that the way to create jobs is to cut government spending, will destroy this one chance. Make sure it doesn't happen.

Monday, October 29, 2012

So far (8:00 am eastern time) I'm cool. It's getting a bit breezy but not so as to bring down any timber. I've got my 'lectric, just had my morning cup of joe, and . .. whoops, there goes a big gust. The National Weather Service is promising me tropical storm force winds soon enough, so I'm staying home.

I hereby command you to read Joe Romm on this situation. He very much likes the term Frankenstorm. My grandfather was a professor of English literature, who had a wide range of interests from Chaucer to Faulkner. Along the way he wrote about Mary Shelly's Frankenstein. The novel's central metaphor is taken to represent the ways in which scientific and technological advances can unleash unforeseeable consequences. (It's subtitle, in case you didn't know, is The New Prometheus. The Gods punished Prometheus for giving fire to humanity but we're all getting it on the chin for our collective folly in this world.)

Romm explains why this unprecedented event is happening now. What is unprecedented about it? It starts out as the largest hurricane in known history. That means, not the hurricane with the most powerful central winds, but the hurricane with the largest extent of tropical force winds, hundreds of miles in width. It could form as late in the season as it did, and retain its power as a hurricane, because the ocean is much warmer than it has been previously -- some 5 degrees Fahrenheit off the mid-Atlantic coast. At the same time, the disappearance of arctic sea ice and the reduced arctic temperature gradient causes the jet stream to develop deep southerly loops. An unprecedented blocking high off of Greenland and a powerful winter storm with its central low pressure moving into the central U.S. are causing the hurricane to make a highly unusual west turn into New Jersey, where it is colliding with the winter storm to create a hybrid which has never been seen before.

We'll see how extensive the wind damage, including power outages, really turn out to be, and whether Manhattan is inundated by the surge. Meanwhile, I'll be catching up on my reading. I'll let you know what Habermas says about Lifeworld and System. And I'll try to get back to you once the woods start crashing down around me, if the technology holds up well enough.

Sunday, October 28, 2012

I expect to lose electricity some time tomorrow, there's no telling how long the computer battery will last or whether Verizon will be able to get me to your Intertubes anyway. So I might as well get it while I can.

I have a five gallon can of potable water in the kitchen, a bucket in the bathroom for toilet flushing and two big tubs on the porch to scoop more out of. I'm building up the ice supply, have non-perishable food laid in and plenty of candles. The wood rack is full so I don't have to brave the elements. I'll just sit here and listen to the trees crashing down. Should be fun.

My aunt owns a beachfront house in Clinton, CT. No, she's not rich. She's the widow of a preacher, they had a bachelor friend who left the house to them. Fortunately her property is on a bluff about 20 feet above sea level. Her house should be okay but I expect the surge will overtop her seawall and possibly wash out her stairs and take away a chunk of front yard. Anyway she and my mother are going to stay at my cousin's house, well inland. They have a generator. Don't want to think about all the old folks who are going to have to ride it out alone. If you know any such people, check on them please.

What's really annoying about this is that we're getting used to it. I didn't get a generator after last year's serial collapses of civilization because I figured, what's the chance of it happening again? Well I'm a fool. We're all fools, who brought this on ourselves. Maybe we'll wake up.

First thing to do, when you do awake: take a solemn vow never, ever, to vote for any Republican candidate, for any office, under any circumstances. Republican=Koch=death.

Friday, October 26, 2012

. . . but, you might want to know that this pretty good study finds that taking benzodiazapines -- i.e. tranquilizers like Valium -- increases the risk of dementia by about 50%.

Guidelines call for these drugs to be used only on a short-term basis, but they are very widely prescribed, they are addictive, and many people take them for years on end. As a matter of fact many people doctor shop to get excessive benzo prescriptions just as others seek opioids.

This study doesn't absolutely drive the final nail into the coffin. It's difficult to correct for confounding by indication in this situation because symptoms that may foreshadow dementia could also be reasons for prescribing and taking these drugs. However, this study is carefully designed to account for that problem as much as possible, and it adds a more powerful and robust finding to a growing body of evidence.

As far as I'm concerned, dementia is the worst thing that can happen to you. It's also really unfortunate for your family and friends, and for society. Now we actually have a way of avoiding a substantial number of cases, by not taking tranquilizers. This is personal, by the way. My father died after a long, horrific journey with dementia. At one point, when he had a crisis, my mother's doctor gave her a big box of Valium. I'm happy to report that I advised her not to take it, and she threw it away.

Unfortunately, it's very difficult to get from findings such as this to real changes in clinical practice.

Wednesday, October 24, 2012

Indiana senatorial candidate Richard Mourdock has actually done us all a favor by forcing a public discussion about theology. That is a realm that has heretofore been off limits in politics. I'll bet a lot of people might be interested to know more about the Mormon religion, but we aren't allowed to talk about it. Now we at least get to talk about Christianity.

In order to be a Christian, you absolutely must compartmentalize your thinking, so as to wall off what would be fatal conflicts if the wrong pieces ever came in contact with each other. Think about natural disasters. The reporters will go to a town that has been devastated by a tornado, and the survivors will all be giving thanks to God for protecting them. Of course, the people next door, maybe including your aunt and your cousins, are all dead or maimed. Hmm.

The miners are trapped underground.. A crew of 100 shows up with drilling equipment and works without sleep for five days, and gets them out, except for the guys who died in the initial collapse. Everybody thanks God for saving the miners. Hmm.

Your daughter is raped. Amazingly, even though it's a legitimate rape, the normal means the female body has to "shut all that down" fail in this case, and she's pregnant. God is all powerful, all knowing, and therefore one can only conclude that God intended for that to happen.

As a matter of fact, God knew at the beginning of time that after he got Mary pregnant, king Herod would get wind of it and murder all the babies in town. He intended for that to happen. God knew that Hitler was going to try to murder all the Jews in Europe. He intended for that to happen. God intended for me to lose my hair, for that matter, and he intended for you to get poison ivy. He intended it all. Hmm.